=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740799584
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERTY RESOURCES HOME CHOICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 N 8TH ST STE 600
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-2422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-634-2000
-----------------------------------------------------
Fax | 215-701-8759
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 N 8TH ST STE 600
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-2422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-634-2000
-----------------------------------------------------
Fax | 215-701-8759
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | FERMINA MADDOX
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-634-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 23213601
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------